ICD-10 transition: ‘No big deal’ or dealbreaker?

The US healthcare industry is undergoing a massive change with the adoption and implementation of the ICD-10 (International Classification of Disease, tenth revision) code set effective October 1, 2014. While the mental health industry has historically been “immune” from many of healthcare’s major changes, the ICD-10 transition is an exception. This transition will deeply affect both clinical and revenue operations in behavioral health organizations. We will likely have two codes sets we must rely on for both these operations moving forward: using the DSM-5 for clinical purposes and the ICD-10 for revenue purposes.

The ICD-9 and ICD-10 code sets are medicine’s equivalent to recent revisions of our DSM manuals. Each revision of the ICD codes sets out, in a standardized manner across the globe, all the medical diseases, conditions, and treatments identified to date. Published by the World Health Organization, these codes are used by everyone to document and diagnose problems, track public health, and identify the prevalence of diseases including “mental diseases” worldwide. The ICD-9 contains approximately 14,000 codes; the ICD-10 contains 68,000+ codes. This is an overwhelming change in the industry.

Let’s start by understanding how the transition from the current DSM-IV-TR/ICD-9 to the new ICD-10/DSM-5 will affect you, in your organization. That means a few questions:

1) What are the sources of your organization’s revenue? What is the mix in percent?

Please fill out a chart like this one with the appropriate revenue mix numbers in the second column.

Revenue source

Share of mix?

Affected by DSM-5 change?

Affected by ICD-10?

Probable risk?

Client self-pay

_______%

Not Likely

Not Likely unless consumer interfaces directly with insurer for benefits

Low

Grant or philanthropic

_______%

Possibly-if DSM-5 codes are needed for qualification, tracking or measurement.

Possibly-If ICD-10 codes are needed for qualification or tracking

Low to Moderate

Public payers

- Medicare

- Medicaid

_______%

_______%

Probably-if DSM-5 codes are required for precertification or authorizations

Yes

High

Comm. insurers

- Insurer 1

- Insurer 2

- Insurer 3

_______%

_______%

_______%

Probably-if DSM-5 codes are required for precertification or authorizations

Yes

High

I think you get the point. The more your organization relies on third-party payers (public or commercial) for significant portions of its revenue, the more vulnerable you are to encounter significant delays in payment, caused by rejected claims or reimbursement changes, associated with the transition from ICD-9 to ICD-10 codes.

Can your organization live through a revenue interruption? One way to be sure it can is to accumulate some significant cash reserves. Just like the CPT codes changes in 2013, it is difficult to anticipate the revenue cycle glitches with the ICD-10 transition. Therefore, having 3-4 months of cash reserves on hand is highly recommended.

Question 2): Are your clinical operations ready for the transition?

Clinical operations include coding, documentation, eligibility, authorizations, and more. In some cases, third parties may require the use of DSM-5 codes for “clinical documentation,” though you must use ICD-10 codes for billing purposes. With that in mind, it may be useful to review a few of the key changes between the DSM-IV-TR and the DSM-5. (See Figure 2, in photo display.) You will notice in the new DSM-5 that the codes are structurally different than those in the familiar DSM-IV-TR format. Most mental health clinicians have not been aware that their DSM-IV-TR codes aligned with the ICD-9 codes in about 98% of the cases. That similarity made building “crosswalks” between the code sets relatively easy.

But that similarity can no longer be taken for granted. The new DSM-5 and ICD-10 code sets do not align exactly and clinicians are more likely to struggle when they have to translate diagnoses and treatment over to the appropriate ICD-10 codes for claim purposes. Therefore, building and testing an accurate and accessible “crosswalk” between the two code sets will be a critical part of readiness for your organization.

DSM-IV-TR/ICD-9

DSM-5/ICD-10

Diagnostic changes

None planned

Additional diagnoses

Some diagnoses dropped

Changes in diagnostic levels/criteria/specificity

Use

Clinical documentation for treatment

ICD-9 coding for claims

Clinical documentation for treatment

ICD-10 coding for claims

Similarity with ICD codes

DSM-IV-TR and ICD-9 codes correlate closely. There is a code-for-code match between them for about 98% of behavioral health conditions.

DSM-5 and ICD-10 codes do not correlate as closely

Crosswalks

Relatively easy

More difficult, due to larger number of ICD-10 codes, differences in nomenclature, each classification system has unique features, different diagnostic criteria, and documentation requirements

But the challenges in moving to ICD-10 do not end there. Other challenges and questions include these:

1) Every service rendered as of 10/1/2014 must use ICD-10 codes on associated claims in order to obtain payment. Therefore, a recommended and best practice is to engage in dual coding and claims processes to prepare for the transition.

2) Many organizations are making the code-set switch at or about the same time. You must consider not only how your organization is handling the switch, but more important, how and when your business partners (and payers) are handling the switch. To ensure your own revenue stream, you’ve got to know what they’re up to—in detail—and be mindful that their timelines will be different, and will likely affect, your own.

3) What does each of your public or commercial payers want in terms of clinical documentation classification systems? Do they want: DSM-V, ICD-10 or both? How will you handle and implement these clinically and administratively?

4) How are the payers mapping the reimbursement schedules and what changes or implications will this have on your revenue? We learned from the CPT code changes that some payers are simply not reimbursing for certain CPT codes anymore. How will this affect your contracts?

5) Given the timetables and progress for each payer, how much time will your organization have to make and test the needed changes? When should you start your internal ICD-10 transition planning? Provider organizations have a lot of work to do internally to get ready for ICD-10 including planning and implementing changes to clinical documentation, dual coding, staff training, payer contracts, claim denial plans, crosswalks, and more. All of these are things that only your organization can do and must do for itself.

If your organization is affected by the ICD-10 coding requirements, you’ve got a good bit of work ahead, even if your transition plans are already in place. If you’re still working on those plans, or have barely started, remember the goals: Ensuring that your organization is tested and “ready” before the October 1, 2014 deadline; avoiding (or mitigating via cash reserves) revenue cycle disruptions, and, if you haven’t already done so, getting sound advice and needed answers from payers, peer organizations, internal personnel, and other trusted professionals.

Lisette Wright, M.A. is a consultant on IT projects in the health and human services industry. Her background also includes providing direct clinical services. She is Executive Director of Behavioral Health Solutions, P.A. Minneapolis, MN and can be reached at lwright@behavioralhealthsolutionsmn.com.